HomeMy WebLinkAbout040-1175-70-000 r
n p ic 'C n d _1
0 = fu
'**
I m
3 In
3' Z —I N Z O p A A
0 •
n m 0 3 (n 0 00 (D
CL 3 O
m = CD (o rn
I j � C (D m Z � �^ � �,
3 (D O o o - O
CA
v
O O h CD O (D w O O
CD o w ,
V N 3 a O � ''I p SI
o o
(n -< D ID a m
m o M y CD o
w o
c CL CL
3 O 3 = V
0 CD
CL
? Z O �1
°� 0 000C,
N 22 m N (n Mti.
v
C CA cn CO) 0) . `•�1
N d cr 0 n
0
OG
N 3 (D
CD
z `
I Z rr
° z z
@ O D m
ZY
CO �•
'D (D CO
c N
V Calf
C
w o a
a 3
CD
Z (D s -i Cl)
c
a a z
0 ..
Z N
W T co
C 3
L z
O N
I y � �
a
m
0
3 CA) c
0 o a
0
CD m
N
I a
7
CL
I m
_ Z
a
I
I fi
ti
I V
N
O
O
I A
O A
N 00
rn
0 �. p
CD
1
a O N O
N ~ O V
y
�r et c
a O I
N �
'O
N yw . E (D'o
rn'0 O M E
\ C O 0 0 V >
V V O >,c0 c0 O
o x co a� aU
0
O O N 7 O
Q N NNMLL a)N
N
O•N(n(6
ca
c6.@+ a) N
�
p i Cc
N C'O O C
E O C C > O
« N O 4 E CL O a=
c Z � :3 (D
LL c caaa) uiY°O
m a _
°_ nYV� mN'
C N
O C N co 0 0
o a a)co ago
E Q a . v 0 CL(N
as
I
m
0
N E
Z '' w 0
N H Z d m
I
C C7
O z a c
oN
Q, a
E
� I
N O
a)
o
LO 4. O
• m N i+ O
N O d Q. = V .V N
O C N w `=
N � z � z pzo
� z I
U j
x =
c
d
v U ca G G a` E co
N N H H H FLI N CL
> 3 3 3
• 4-i v a a a
a LO
7 O N N r n
U OD CD
LLj a v ao o
O N N N N
H p p E N O Q7
a
(� Q u
C U
Ai O O J y C
O
O b+ w T U d j N I- .-- CO V
Ro m c c u a °o °o 0 0 0 1
co
L Lo O 3 LL N h N
I\ N 0 ` \ a) (D C 7 V N N ap
m = " n N Z Z v
• ~ a a N
00 O y R d rn
�y O N Ili GO O z _
V ik = s
CC ►'
� I € a
# .EI L: a .-
CL
CS_1 A U a ',' 0 t� U
r `
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front,.O Side, O Rear,0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Lenith: Number of Lines: Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear,0 Ft .
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: 6J-ADO qAL, Number of pits: � Diameter:
Liquid depth: Bottom of seepage pit elevation: 0 ,6 Q
Area Built: J-000 FT
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one) .
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: oG Plumber on job:
IV V
License Number: 0 D
3/84:mj
I
A
•
Form - STC - 104
4 AS BUILT SANITARY SYSTEM REPORT
OWNER t/l�E / /FyE/t..(� TOWNSHIP ollz>_ SEC. T oCQ N-R oZOW
ADDRESS � ST. CROIX COUNTY, WISCONSIN
SUBDIVISION �, /�. LOT 2 ` LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•l.HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
�tl'LAG�/�7En.�T SY.f7�m
NO/LT)J PriOPFRTY LZivfi {
13,/7=Ton oF w6 L
� Fxzs'rsivG � _�` L"x�tTSn�G oiu vEwr�Y
f GAAA GE
\ E
AMN{^A
Exz"T"G
IZ�rsDFNCE �---- -� A66. ��,
tN=LEO
ExZrTINL Q 1(JRAr.�FZrinIF-��--�� I Dn ALL
p v.y' ' r T P.L.o L:47Y LawE
Ivy I_XSSIIr�b /U»dING-j � ��
D^Ykzj L
P/leA92TY LXrvE f
ANNt/ i
d PAC l WAINED
A6L. COVE 2�
/V07'e:Ay-ry Z/VLETS SrvvtrtTS = 9S. '9 3
D N .QnT/J oLZ6 UO GIOL .02Y I.vELL�'
SO L4T)4 /01t0Pet7Y LX,C-
I+CATE NORTH ARROW
/V o .f'C A -
BENCHMARK: Describe the vertical reference point used 1-70' 0 OF RX2S7'7-,q b./ELL
Elevation of vertical reference point: Proposed slope at site: -���-�--
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,Q Rear, O feet
From nearest property line Front,0 Side,0 Rear,0 feet
Number of feet from: well , building:
(Include this information of the above plot plan) ( 2 reference dimensions to septic tank)
nnr, n'+��rnfr. nTTr
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969, BUREAU OF PLUMBING
MADISON,WI 53707
CONVENTIONAL 1:1 ALTERNATIVE State Plan l.D.Number:
(lf assigned)
❑Holding Tank El In-Ground Pressure El Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: r.7
Joe Meyeu Rt. 30 Box 113, Cove Road, Huctson, W1 f J �'" ('_S"7
BENCH MARK(Permanent reference pointl DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.:
NW NW, Section 24, T28N-R20W, Town o4 Ttcoy
Name of Plumber: IMP/MPRSW No.: County: Sanitary Permit Number:
GoAy Zappa 3300 S Ctcoix 88462
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: rUIDCAPACITY: T N LET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ONO ❑YES ❑NO
BEDDING: VENT DIA.: VENT MATL.: IHIG ATER R OF OA PROPERTY WELL: BUILDING: VENT TO FRESH
ALAR AIRINLET.
EET FROM LINE:
DYES ONO NO 1EAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIP ON MANUFACTURER. WRNING LABEL LOCKING COVER -
OVIDED: PROVIDED:
❑YES ❑NO NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF jRDFrRTY WELL BUILDING. V NTTO FRESH
(DIFFERENCE BETWEEN FEET FROM AIR INLET.
PUMP ON AND OFF) ❑YES 1:1 NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING. COVER INSIDE CIA. SPITS LIQUID
BED/TRENCH TRENCHES: MATERIAL: PIT DEPT
DIMENSIONS
GRAVEL DEPTH FILL DEPTH jDISTRPI E DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR] NUMBER OF PROPER�TJY WELL BUILDING. VENT TO FR SH
BELOW PIPES: ABOVE COVER: ELEV.INLET ELEV.END: PIPES: FEET FROM LINE �� / AlFyl yl
NEAREST---► f� 4p tif� �/L14°7_
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
OYES ONO
SOIL COVER TEXTURE PERMANENT MARKERS: OBSERVATION WELLS
❑YES 1:1 NO ❑YES NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED
CENTER: EDGES. —]YES NO
❑YES ❑NO ❑YES 1:1 NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH: NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR,PIPE MANIFOLD MATERIAL'. IN. -ISTH. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING
ELEV.: ELEV.. DIA.: ELEV.: PIPES DIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANSGAL LIFT CORRESPONDS TO APPROVED
1:1 YES 1:1 NO 1:1 YES NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF LRfOE ERTY WELL: BUILDING:FEET FR
DYES ❑NO ❑YES ❑NO N
I
Sketch System on Retain in county file for audit.
Reverse Side. TITLE
SIGNA
DILHR SBD 6710(R.01/82) �,
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT: '
1. This sanitary permit is valid for two (2) years;
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable;
3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation;
5. Private sewage systems must be properly maintained. The septic tanks) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
Il. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 sea*
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
Ill. Purpose of application: Check only one in ##1. Complete##2 if permit is for tank replacement, reconnection or
repair,
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8'/2 x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or.other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems: replacement
system areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form.
---------------------------------------------------------------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
On May 4, 1984; 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the t�
result of over 2 years of steady negotiation and public debate. The groundwater bill Ground( ae'r —
included the creation of surcharges (fees) for a number of regulated practices which Wiscor� in`S
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried >'reasure
is used in your building is returned to the groundwater through your soil absorption o
system or the disposal site used by your holding tank pumper.
U'
The monies collected through these surcharges are credited to the groundwater fund adminis
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
vvater, groundwater contamination investigations and establishment of standards. GroundwatE�-,
it's worth protecting.
LDD4398(;2.03/86)
{� SANITARY PERMIT APPLICATION COUNTY
1]'DILHR In accord with ILHR 83.05,Wis.Adm. Code
STATE SANITARY PERMIT#
Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8Y2 x 11 inches in size.
—See reverse side for instructions for completing this application. PETITION
1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO
PROPERTY OWNER PROPERTY LOCATION
/V-1,1 a NtV Ya, S t Y T W, N, R Ab E (or)W
PROPERTY OWNER' AILING ADDRESS LOT BER BLOCK NUMBER SUBDIVISION NAME
Ifavir Ad ST CAOXX n6yr
CITY,STATE ZIP CODE -0 NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
�/� ❑ VILLAGE
II. TYPE Of BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family / OR ❑ Public(Specify):
Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. El New b. Ill Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2)
1. a. X Conventional b. ❑Alternative C. ❑ Experimental
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. ❑ seepage Bed b. ❑seepage Trench c. ®Seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):
79 0 ,00 Feet ®Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in g allons Total #of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank
Lift Pump Tank/Siphon Chamber d b 19 ❑ ❑
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name(Print): Plumber's Signature:(No Stamps) MPRSW No.: Business Phone Number:
CAM /4 ,7 00 7/S n S O
Plumber's Address(Street,City,State,Zip Code): Name of Designer:
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST#
lZojefdrr 64,6r-erc447' -U rdMI
ST's ADDRESS(Streyt,City,State,Zip Code) Phone Number:
r. /6 r 26 - AMS
1X. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
NApproved ❑ Owner Given Initial n Surcharge Fee
Adverse Determination
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
APPLICATION FOR SANITARY PERMIT
STC - 100
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of the permit
issuance. Should this development be intended for resale by owner/contractor, ("spec
house"), then a second form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property _ o$� , meyer-s
Location of Property ✓) Section , T_2N-R�Q W
Township
Mailing Address /3
Address of Site e�
. Subdivision Name
Lot Number 2
Previous Owner of Property
Total Size of Parcel S x
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number - as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Warranty Deed which includes a Document number, volume and page number, and the
Seal of the Register of Deeds. In addition, a certified survey, if available, would be
helpful so as to avoid delays of the reviewing process. If the deed description refer-
ences to a Certified Survey Map; the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTV OWNER CERTIFICATION
I (We) centisy that att statement,6 on thiz 6onm ane true to the be,6x o6 my (oun)
knowledge; that I (we) am (ane) the owners) oS the pnopenty dedcA bed in thi.6
.insonmation Sown, by vi tue o6 a wa4 awty deed teco&ded in the 066ice o6 the
County Reg.cdten o6 Deeds ad Document No. ; and that I (we) peed entey
own the pnoposed .6 to Son the sewage dispo.a .6y6 em (on I (we) have obtained an
easement, to )tun with the above debcnibed pnopenty, San the conbtnucti.on o6 said
system, and the same has been dut teemded in the 046iee o6 the County Reg.isten o6
Deede, as Document No. S(D7.�) .
�Z 222=��)(,,
Sl& g,,OWNIR SIGNATURE OF CO-0 ER (IF APPLICABLE)
DATE SIGWED DATE S GNED
ep rp
b
Cb
CL
r�
c
Finn 65.6. warrants Des"bort Farm (STwTs of wlsooxSM) rabndw m Sea cififte Boot i Nauseam Gan
(8ee.!95.16.Wit statutes) Form No.6
�J 6 G VOL 543 F""f IV
Rio �JubritfurP, Madeby George F. Setzer and Susan C. Setzer, husband
wife
grantors ,of St. Croix County, Wisconsin,hereby conveys
Joseph E. Meyers,and warrants to P Y , Jr. and Susan A. Meyers, husband and wlge,
as joint tenants and not as tenants in common .
Minnesota •
grantee s ,of Hennepin County, WIS&€A&for
thesumof ONE DOLLAR ($1. 00) AND OTHER GOOD AND VALUABLE CONSIDERATION .
the following tract of land in St. Croix County,State of Wisconsin:
Lot 26, St. Croix Cove Subdivision, according to the plat thereof on
file and of record in the office of the Register of Deeds within and
for said County and State.
Subject to and together with protective covenants of record.
REGISTERS OFFICE "I'1< .'�,;:• .�' �
ST. CROIX CO., WIS.
2 2nd_
Recd. for Record this___ F�
day of--!Et. A.D. 1975
at ---- 3:30 P. , M:
Qy Register W Deeds
In Wttntoo Mbutot, the said grantors have hereunto set their ban a d seals this
day of June ,A.D.,19 76
Signed and Sealed in Presence of __ ..(SEAL)
Georges F. Setzer
.(SEAL)
Susan C
R. H. Thoom-s-sen1 )Jr. _ ..(SEAL)
,Ll.I
Alice M. Ekstrom ..(SEAL)
Watt of MfOronotn, )
St. Croix ? ss.
-- •• County.!
Personally came before me, this day of June ,A.D.,19 76 .
the above named George F. Setzer and Susan C. Setzer ,
to me..known to be the person s who executed the foregoing instrument 4 aclrnow ed the sam
as their free act and deed.
1.AMn^,�l✓V,.nnnr,nr,n�.r,^././^r,P.?,�..•.'..,,^nM.�■ ___. .. _... ......
R H li1(ni _,I R.
R. H. Thomssen, _Jr.
�• ' ' .Notary Public, � Ramsey County,A#"
.32
ti,n�Jf-wr My commission expires A.D 19
Drafted by R- H. Thomssen, Jr. , Clapp-Thomssen ComysInv, , Fourth St.
St. Paul, Minnesota, 55101
tX,B.-Ch.59-Wis.8ta,*provides that all lnstwments to be reeorded a:iali have plalniy printed or typewritten thereon the names of the granters.
,A.
• O
-1
N
9� N N
z
/9X 0 CA
A�t N, I —:--,._
z T
"TN
Tj
O
rr) �v
rp ��a
CA
O O
.rNti trt
d) ` x
O G'
t,
m
r
� I
z
T
e1d f
m
i
a n
� r
� tZ*
• � U1
(T1
�... -j M
rr
r
� � FD
® CD
VF It C3
0 X
rr CD
.. �i
0
6-0 - Ol a�Fq
4•=�
- H
H
a
• STC - 105 re
a
H
SEPTIC TANK MAINTENANCE AGREEMENT 0
St . Croix County x
W
a
OWNER/B.WFEtt 1�:>S zzle yG cg Sn M
ROUTE/BOX NUMBER oX Fire Number 8s
90 / /
.CITY/STATE /5V,0-7 ZIP
PROPERTY LOCATION: 14, 36, Section, T2N , R-W,
Town of -rrnn e , St . Croix County,
Subdivision JSt (fre2;. &me'. Lot number 9-)(0_.
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes . Proper maintenance con-
sists of pumping out the septic tank every three years or sooner ,
if needed , by a licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St . Croix. County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1 , 1978 . St . Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St . Croix County Zoning a
certification form, signed by the owner and by a master plumber ,
journeyman plumber , restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping ( if nec-
essary) , the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration.
0
E
I/WE, the undersigned, have read the above requirements and agree N
to maintain the private sewage disposal system in accordance with x
M
the standards set forth, herein, as set by the Wisconsin Depart- ►v
ment of Natural Resources. Certification form must be completed
and returned to the St . Croix County Zoning Offkge within 30 days
of the three year expiration date .
SIGNED
•
DATE
St . Croix County Zoning Office
P.O. Box 98,
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
L Yk
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 `
To he a complete and accurate soil test,your report must ir;clude. `
1. Complete legal description;
2. The use section must clearly indicate whether this is a residence or commercial project;
3, MAXIMUM number of bedrooms or commercial use planned;
4. Is this a new or replacement system;
5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
5. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A
separate sheet may be used if desired;
8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are perrnanent;
B. Complete all appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemp-
tion, if appropriate;
10, If the information (such as flood plain, elevation)does not apply, place N.A. in the appropriate box;
I1. Sign the form and place your current address and your Certification number;
12. Make legible copies and distribute as reduired. ALL SOIL TESTS MUST BE FILED VNITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Sail Separates and Textures tither Symbols
st - Stony; (over 10") BR --- Bedrock
cob -- Cobble (3- 13") SS _, Sandstone
gr -.- Gravel (under 3") LS - Limestone
s - Sand HGW - Nigh Groundwater
cs - Coarse Sand Perc: Percolation Rage
reed s - LJlediun Sand W - W(11
f Fine Sand Bldg Building
is Loamy Sand Greater 'Than
s1 - Sandy Lo ar a <' _ Less Than
Ml 1_r,arr Bn - Brown
�'sil -- Silt Loan) BI Black
s.i gilt Coy __ Gray
'cl - Clay Loam Y Yellow
scl Sandy Clay Loam R - Red
sicl - Silty Clay Loarn not - Mottles
s€° - Sandy Clay -- i"v;th
sic Silty Clay fif few, line, faint
Ke
Cfa,y CC .- t;Ornmon, coarse
pI - Peat min - klany, mediurn
;r. _- Muck d distinct
p - prominent
H VV -- High water level,
1 Six general soil textures surface water
far liquid waste disposal BM Bench Mark
VRP Vertical Reference Point
TO THE OWNER:
This soil test report is the first step in securing a sanitary permit. The county orthe Department may request
verification of this soil test in the field prior to permit issuance. A complete set of plans for the private
sewage system and a permit application must be submitted to the appropriate local authority in order to
obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction.
4uivT&- 7EST e-dAPDirio.vs ,: svvuy', ,�d�°� ,l/o `ipo.rT.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INPUSTR.Y, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON WI 537907 9 53707
HUMAN RELATIONS
(H63.09(1)& Chapter 145.045)
LOCATION: SECTION: TOWNSHI LOT NO.:BLK.NO.: SUBDIVISION NAME:
Nw 1/ 1/ iY /Tie N/1120E for 78491 I sr. e*Ablx cr&&Z'
COUNTY OWNER'S Bt YTR'S NAME: MAILING ADDRESS:
S? c pcX Jre�?E �/ yEiQS �i-3 aax //3 tovF''GQ hwDJa-v, his .
USE DATES OBSERVATIONS MADE
NO.BEDR .: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS:1PERCOLATION TESTS:
Residence J ,�/,� ❑New Replace (/yw• Z i fee
RATING:S=Site suitable for system U=Site unsuitable for system .Ses ��/ 'c ',e;f T IS
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional)
F s ❑u ❑s ❑u ❑s ❑u ❑s ❑u ❑s Z
1f Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: G'�/i�,t J. (Floodplain,indicate Floodplain elevation:
PROFILE DESCRIPTIONS 'w !B IF
BORINGI TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER IDEPTH IN. ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.)
33 ' D,N ,Rw. /s, /S ' Z-1 N, j 7. 17'
B- /1.0 10. 70 �- > /1.0 CS 4 6-R -
B-y /2.Of /O-Z oB , rl1.p ' ico BN• /s, iS ' 8,r.. s, 90' a&, .
csW- XJ' i0 S� 9S8' r0
R
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 1 PERIOD 2 PERIOD PER INCH
P-
P_ �PD� — 5r--S -rr-6466i vw
P- L-�!!&1117y Y100e v 40-4tz S'
P-_ " O
P
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope. �1 0/A1 r (/��� ��y�G fiS 7e yQ ,
SYSTEM ELEVATION
f
1 I
E
, .
I t
P A
_ ..
tN
1 1
i r
1 a
I 7
I '
I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the pr e '� ecified in the Wisconsin
Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge a e i -'
NAME(print): TESTS WERE COMPLETED ON:
HOflAESITE SEPTIC PLUMBING CO.
T. 'NEIL RO..HUDSON, WIS. 54016 A60.24 , I�
ADDRESS: ROBERT ULBRICK CERTIFICATION NUMBER: IPHONE NUMB ( tiona0:
WIS.MASTER PLUMBER LIC.NO. 3307 M.P.R1
CST SIGNATURE:
DISTRIBUTION:Original and one copy�o Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) ` —OVER —
REPORT ON SOIL BORINGS & PERCOLATION TESTS 115 PLOT PLAN
,Project I.D. 10E- 'Af �E'�t°i S COVE
HOMESITE SEPTIC PLUMPING CO
LEGEND IT.i VNEIL RD.,HUI)%N.WIS.5416
ROBERT ULBROT
s Backhoe Fits MRS.MASTER PLUMOERLIC.No.3WKP.RR
MINN.INSTALLER&DESIGNER I.W.No.We
X Perc Locations C.S.T. 2482
� = Existing Well
Vertical Reference Point ; Top moST po%uT Oj- AW1 e4S,r.V6-
Elevation of Vertical Reference Point /D �• 0
-- Lot Line A
SCALE: / " 20
30
y"veyT 33
` � t
i F- d 0 ' - 36 .
Ile " b
PIP
B .
7 21
gg a
Soot Col' L�u� - A'y
Al
r
y
&13 7
•
SECT Oh/ 1 ,2x"-r
13./7- =ToP ar Exrs7SNG i..,FLL
ExrsT1NL w�cL-�� �°� / noJ�cr
Jot I* Icyelzs
EXZSTtavG 1 =7X,,G 6r. 44XVEI AY
IA CL/'hFrvT SYSTEM
GAaq r_ ��
T°wni of T/'LO Y
ST C40XX CO.
CXzSTS1vG - --—
I
RESSpEn�c,E �txrrTxNG I '�
/y'7CrITSNG O 'FNZLIsD I
X600 GAL
/�io Cuo L �DRYwELL.
rb°Tic.TAnK d/taTN' ���
F.'eLr] 131
6XIJTSNG /ouv
.S'TACAS
cNAr�s£2 niE�„ EffG.c..7 H LI+�E / �'
°
i
Ana
�'AriN DlI.Yw81.t_ A/to/�F./1TY
G.SNIF
�WE!'7 P/lvNE0.T�� 9� ba 00 CAL A10 SCALE
Lz�@ NOTE= CXISTSN G D/s'.vzn, FseLA /hpreu�oL
To /2E /ZAA-EO A-0 12EPLACED ,3 L , -CUVt gal
6V2TN CUYN/JAGT'Ez G/UJIV[/LA/L
/'7A-rFiLS.oL I-,iNERE I'a��s6�o
EFFluc�vT Z-r vc Cno u-eS 7wa/L.
owE2
SOw7H AnoPCaTY LXIvC 10.1�12Y3o
SOSL T EST-T vG ley
/Zo6E2T ULI�RIGNT S=`�Ntd
L.a.C IF N GIB
l c J�ATE
CZoss SEcrxon/ of / 'cGOD (SAL .
VENT CAP �/LYI�vELL /�/ta/�vtED 1: nr N G.nAor /00.9?
/R�/SovE C,/tAOE
6
VENT STACIE MANNULE
C.T.y�, 3 2zuGS
ToP co; AGG.
ExcA VATgo IuA ,ALL _ _ _ --__, IE�XC/J V►vTED SSDF ItiA�t
J' d/ 7o EXTENo 6'PA&7
® C2NSS.0E 1Ozn. OF /
y I C
1 /sPE
D(kY £LL
❑ ❑
, );
��� >
y
�� ❑ ❑ ❑ c, ❑ ❑ [J- �� "20
�r �a r `. ❑ ❑ 0 0 0 0 0 0
/'77siv_ A'V."VUL/V/L TI'Act
"., OF / "I.iAPhlEo iOGG.
�. ❑ ❑ 00, 0 CT ❑ ❑ a 'Z�
❑ Q ❑ O ❑ ❑ ❑
❑ ❑ ❑ ❑ U ❑ ❑ ❑
J ❑ ❑_❑ ❑ CJ ❑ [� �� /volt== I,,.YE 2r,/ t`F1=LuEwT
C ��..
❑ ❑ J p EJ ❑ ❑ ❑ �, J� L,zwE ?o �t LEUtL,
.y�J
0 C] Foy EgUAL Dssr
1 l=LLr v. of BAYWELL /:Z(>&/L OF ZFfLaEn/T
a % Ts X6.00 /=T g-�